BU Health & Medical the Future of Nursing Discussion

Review the National Academy of Medicine’s 2021 report, “The Future of Nursing 2020-2030:
Charting a Path to Achieve Health Equity,”attached below
Write a paper discussing the influence of the report on nursing practice. Include the following:
1.Review the recommendations of The National Academy of Medicine 2021 report and explain
why health equity is significant in this report. Three hundred words
2.Define social determinants of health. Discuss one of the determinants and howthis impacts
health equity. Three hundred words
3.Describe the role nurses have in improving health equity and impacting socialneeds. Three
hundred words
4.Discuss the significance of self-care to decrease nursing burnout. What self-careand evidencebased strategies are available for nurses to maintain personaland spiritual health? Three hundred
words
UseAPA 7thedition and cite at least 3 refrenc es less than 5 years old
This PDF is available at http://nap.nationalacademies.org/25982
The Future of Nursing 2020-2030:
Charting a Path to Achieve Health
Equity (2021)
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466 pages | 6 x 9 | PAPERBACK
ISBN 978-0-309-68506-1 | DOI 10.17226/25982
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Mary K. Wakefield, David R. Williams, Suzanne Le Menestrel, and Jennifer Lalitha
Flaubert, Editors; Committee on the Future of Nursing 2020 2030; National
Academy of Medicine; National Academies of Sciences, Engineering, and Medicine
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Mary K. Wakefield, David R. Williams, Suzanne Le Menestrel, and
Jennifer Lalitha Flaubert, Editors
Committee on the Future of Nursing 2020–2030
NATIONAL ACADEMY OF MEDICINE
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by a contract between the National Academy of
Sciences and the Robert Wood Johnson Foundation (Grant Number 76081). Any
opinions, findings, conclusions, or recommendations expressed in this publication
do not necessarily reflect the views of any organization or agency that provided
support for the project.
International Standard Book Number-13: 978-0-309-68506-1
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Suggested citation: National Academies of Sciences, Engineering, and Medicine.
2021. The future of nursing 2020–2030: Charting a path to achieve health equity.
Washington, DC: The National Academies Press. https://doi.org/10.17226/25982.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
The National Academy of Sciences was established in 1863 by an Act
of Congress, signed by President Lincoln, as a private, nongovernmental
institution to advise the nation on issues related to science and technology.
Members are elected by their peers for outstanding contributions to
research. Dr. Marcia McNutt is president.
The National Academy of Engineering was established in 1964 under
the charter of the National Academy of Sciences to bring the practices of
engineering to advising the nation. Members are elected by their peers
for extraordinary contributions to engineering. Dr. John L. Anderson is
president.
The National Academy of Medicine (formerly the Institute of Medicine)
was established in 1970 under the charter of the National Academy of
Sciences to advise the nation on medical and health issues. Members are
elected by their peers for distinguished contributions to medicine and
health. Dr. Victor J. Dzau is president.
The three Academies work together as the National Academies of
Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to
solve complex problems and inform public policy decisions. The National
Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in
matters of science, engineering, and medicine.
Learn more about the National Academies of Sciences, Engineering, and
Medicine at www.nationalacademies.org.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Consensus Study Reports published by the National Academies
of Sciences, Engineering, and Medicine document the evidencebased consensus on the study’s statement of task by an authoring
committee of experts. Reports typically include findings, conclusions,
and recommendations based on information gathered by the
committee and the committee’s deliberations. Each report has been
subjected to a rigorous and independent peer-review process and it
represents the position of the National Academies on the statement of
task.
Proceedings published by the National Academies of Sciences,
Engineering, and Medicine chronicle the presentations and discussions
at a workshop, symposium, or other event convened by the National
Academies. The statements and opinions contained in proceedings are
those of the participants and are not endorsed by other participants, the
planning committee, or the National Academies.
For information about other products and activities of the National
Academies, please visit www.nationalacademies.org/about/whatwedo.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
COMMITTEE ON THE FUTURE OF NURSING 2020–2030
MARY K. WAKEFIELD (Co-Chair), Visiting Professor, The University of
Texas at Austin
DAVID R. WILLIAMS (Co-Chair), Florence and Laura Norman Professor of
Public Health and Chair, Department of Social and Behavioral Sciences,
T.H. Chan School of Public Health, and Professor, Department of African
and African American Studies, Harvard University
MAUREEN BISOGNANO, President Emerita and Senior Fellow, Institute for
Healthcare Improvement
JEFFREY BRENNER, Co-Founder and Chief Medical Officer, JunaCare
PETER I. BUERHAUS, Professor of Nursing, College of Nursing, and
Director, Center for Interdisciplinary Health Workforce Studies, Montana
State University
MARSHALL H. CHIN, Richard Parrillo Family Professor of Healthcare
Ethics, Department of Medicine, University of Chicago
REGINA S. CUNNINGHAM, Chief Executive Officer, Hospital of the
University of Pennsylvania; Adjunct Professor and Assistant Dean, School
of Nursing, University of Pennsylvania
JOSÉ J. ESCARCE, Distinguished Professor of Medicine, David Geffen
School of Medicine, and Distinguished Professor of Health Policy and
Management, Fielding School of Public Health, University of California,
Los Angeles
GREER GLAZER, Schmidlapp Professor of Nursing and Dean, College of
Nursing, University of Cincinnati
MARCUS HENDERSON, Charge Nurse, Adolescent Services, Fairmount
Behavioral Health System; Lecturer, School of Nursing, University of
Pennsylvania
ANGELICA MILLAN, Former Children’s Medical Services Nursing Director,
County of Los Angeles Department of Public Health
JOHN W. ROWE, Julius B. Richmond Professor of Health Policy and Aging,
Mailman School of Public Health, Columbia University
WILLIAM M. SAGE, James R. Dougherty Chair for Faculty Excellence,
School of Law, and Professor of Surgery and Perioperative Care, Dell
Medical School, The University of Texas at Austin
VICTORIA L. TIASE, Director of Research Science and Informatics Strategy,
NewYork-Presbyterian Hospital
WINSTON WONG, Scholar in Residence, University of California, Los
Angeles, Kaiser Permanente Center for Health Equity
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Study Staff
SUZANNE LE MENESTREL, Study Director (from June 2020)
SUSAN B. HASSMILLER, Senior Scholar in Residence and Advisor to the
President on Nursing, National Academy of Medicine
JENNIFER LALITHA FLAUBERT, Program Officer
ADRIENNE FORMENTOS, Research Associate
TOCHI OGBU-MBADIUGHA, Senior Program Assistant (from October
2020)
CARY HAVER, Study Director (until June 2020)
LORI BRENIG, Senior Program Assistant (until May 2020)
CAROL SANDOVAL, Senior Program Assistant (until September 2020)
ASHLEY DARCY-MAHONEY, National Academy of Medicine Distinguished
Nurse Scholar-in-Residence (August 2020 to August 2021)
ALLISON SQUIRES, National Academy of Medicine Distinguished Nurse
Scholar-in-Residence (March 2019 to August 2020)
SHARYL NASS, Senior Board Director, Board on Health Care Services
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Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Reviewers
This Consensus Study Report was reviewed in draft form by individuals
chosen for their diverse perspectives and technical expertise. The purpose of this
independent review is to provide candid and critical comments that will assist
the National Academies of Sciences, Engineering, and Medicine in making each
published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study
charge. The review comments and draft manuscript remain confidential to protect
the integrity of the deliberative process.
We thank the following individuals for their review of this report:
FRANK BAEZ, New York University Langone Health
KENYA V. BEARD, Chamberlain University
PATRICIA FLATLEY BRENNAN, National Library of Medicine
SALLY S. COHEN, New York University
MARY PAT COUIG, The University of New Mexico
FRANCIS J. CROSSON, Kaiser Permanente Bernard J. Tyson School of
Medicine
WILLIAM A. DARITY, JR., Duke University
MARGARET FLINTER, Community Health Center, Inc.
BIANCA K. FROGNER, University of Washington
EMILY A. HAOZOUS, The University of New Mexico
BERNADETTE MAZUREK MELNYK, The Ohio State University
TERI A. MURRAY, Saint Louis University
DANIEL J. PESUT, University of Minnesota
KRISTINE QURESHI, University of Hawai’i at Mānoa
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
viii
REVIEWERS
ROBERT D. REISCHAUER, The Urban Institute
CAROL A. ROMANO, Uniformed Services University of the Health
Sciences
SUSAN E. STONE, Frontier Nursing University and American College of
Nurse-Midwives
DANIEL WEBERG, The Ohio State University
Although the reviewers listed above provided many constructive comments
and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review
of this report was overseen by BOBBIE BERKOWITZ, Columbia University,
and MAXINE HAYES, University of Washington. They were responsible for
making certain that an independent examination of this report was carried out
in accordance with the standards of the National Academies and that all review
comments were carefully considered. Responsibility for the final content rests
entirely with the authoring committee and the National Academies.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Foreword
The year 2020, the bicentennial of Florence Nightingale’s birth, was designated by the World Health Organization (WHO) as the International Year of the
Nurse and the Midwife. According to WHO, “Nurses and midwives play a vital
role in providing health services. These are the people who devote their lives to
caring for mothers and children; giving lifesaving immunizations and health advice; looking after older people and generally meeting everyday essential health
needs. They are often, the first and only point of care in their communities.”
As president of the National Academy of Medicine (NAM) and as a physician who has worked closely with nurses over the decades, I know the central
role of nursing in achieving the high-quality, accessible, and compassionate care
that individuals, families, and communities richly deserve. I am proud that we
can help commemorate this occasion through the release of our latest report, The
Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity.
This report is the third in a series on the future of nursing that we at the
NAM (formerly known as the Institute of Medicine [IOM]) have been privileged
to create with the sponsorship of the Robert Wood Johnson Foundation. The first
of these reports, The Future of Nursing: Leading Change, Advancing Health,
published in 2011, presented a set of bold recommendations to strengthen the
capacity, education, and critical role of the nursing workforce. It emboldened
nurses to play a central role in improving health care for people, families, and
communities around the world. That report, which has served as a blueprint for
the nursing profession, is the National Academies’ second most downloaded
health and medicine report since its release and continues to reach thousands of
nurses and other important stakeholders around the world.
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
x
FOREWORD
The second nursing report, released in 2016, Assessing Progress on the Institute of Medicine Report The Future of Nursing, highlighted promising progress
made since the 2011 report while noting that much more needed to be done. It
outlined three themes central to the future success of the Robert Wood Johnson
Foundation/AARP Future of Nursing Campaign for Action (the Campaign):
the need to build a broader coalition to increase awareness of nurses’ ability
to play a full role in health professions practice, education, collaboration, and
leadership; the need to continue to make promoting diversity in the nursing
workforce a priority; and the need for better data with which to assess and drive
progress.
Alongside these two reports have been the exemplary and steadfast efforts
of the innovative change initiative, the Campaign, in continuing to implement
the recommendations from the first report while working to take on the recommendations of the second in a more robust way. Of note, efforts to create a more
diverse workforce and to expand ways of working with others in and outside of
the health system have served to foreshadow the importance of nurses as key
players in achieving health equity in the United States and globally. No one
profession or group will achieve the health equity needed in this nation without
all health professions, working within and across disciplines, aspiring to advance
the culture required. Working across sectors with steadfast vigilance will be a
necessary ingredient not only in understanding but also in taking real action to
achieve health equity.
With this third report, The Future of Nursing 2020–2030: Charting a Path
to Achieve Health Equity, the NAM and the Robert Wood Johnson Foundation
continue their steadfast collaboration toward promoting a culture of health for
all. Both organizations believe that uneven access to conditions needed for good
health across the United States has been well documented, as have the poor effects on health that result. The growing visibility of the impacts of systemic racism in almost every aspect of people’s lives—policing, health care, the economy,
education—is evident. Now more than ever, the nation sees clearly the need for
an equitable, just, and fair society—one that promotes racial equity, as well as
equity across circumstances, communities, and abilities. The good news is that so
many of us are asking, “How can we do better? How can I do better?” In a time
marked by COVID-19’s unprecedented global health challenges, nurses have
stepped up—many times at great personal cost to themselves.
Nurses have seen firsthand this disease’s inequitable impact on those they
serve. They have also experienced firsthand COVID-19’s inequitable impact on
the profession. Nurses are more likely to die than are other health care professionals, and nurses of color are far more likely to die. As this report points out
with compelling evidence, nurses can play a central role in addressing these inequities across the entire spectrum. The nation cannot achieve true health equity
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
xi
FOREWORD
without nurses, which means it must do better for nurses. They must be supported
in charting a path for themselves while they work to serve others. This report is
intended to do just that.
I am very grateful to the committee for their consensus on the important
recommendations in this report—especially the co-chairs, Mary Wakefield and
David Williams—and to the National Academies staff, including Suzanne Le
Menestrel, Jennifer Flaubert, Adrienne Formentos, and Tochi Ogbu-Mbadiugha,
as well as Susan Hassmiller, who served as senior scholar-in-residence and who
provided continuity between the first and third reports.
This report calls on many within and around the nursing community to take
more definitive action on eliminating systemic racism, whether in schools, institutions, or the profession and its associations. Nurses are powerful in number and in
voice and the world needs their actions now more than ever on how individuals,
families, and communities might best be served in a more equitable fashion. And
in asking nurses to play a central leadership role, I am reminded of the importance
of nurse well-being. Nurses have been called on to do so much in this past year
throughout the COVID-19 pandemic, and the nation must support them, including giving them all of the necessary tools and equipment to do their job in the
best way possible. I am confident that the nursing community and other important
stakeholders will use the recommendations in this report and their evidence base
to lead the way to a more equitable and healthy society.
Victor J. Dzau, M.D.
President, National Academy of Medicine
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Preface
In 2019, the Robert Wood Johnson Foundation (RWJF) sponsored this study
to explore the important contributions of nursing to addressing social determinants of health (SDOH) and health equity in the United States. This was to serve
as a parallel effort to other National Academy of Medicine reports and initiatives
sponsored by RWJF around efforts to create a more robust culture of health in the
United States. The work of this committee began in 2019 after years of evidence
documenting the relationship between SDOH and health outcomes, as well as
broader challenges associated with health and health care equity. By the end of
2020, this report was to be released in a year that was being commemorated by
the World Health Organization as the International Year of the Nurse and the
Midwife.1
Throughout the year, the committee participated in three major town hall
meetings; a series of site visits in and around Seattle, Chicago, and Philadelphia;
and two other public sessions, recordings and materials from which are available
online.2 We heard time and again how the highly complex health and social needs
of people were critical in defining their overall health and well-being, and that of
their families and populations at large.
The committee’s work continued in 2020 with the goal of launching this
report at the end of the year. In March, however, the COVID-19 pandemic hit the
1 See https://www.who.int/campaigns/annual-theme/year-of-the-nurse-and-the-midwife-2020 (accessed April 13, 2021).
2 Town hall recordings and materials can be accessed at https://nam.edu/publications/the-future-ofnursing-2020-2030 (accessed April 13, 2021).
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
xiv
PREFACE
United States, and throughout the year it was evident that the challenges outlined
in this report were vastly magnified by the most devastating health care event in
more than a century. The pandemic, which has since killed nearly 3 million people globally and sickened more than 135 million more,3 laid bare the depth and
breadth of inequity and its impacts on the health and well-being of large swaths
of the nation’s population, disproportionately impacting people of color, those
with low income, and those living in rural areas.
Simultaneously, 2020 taxed the nation’s nursing workforce in ways that had
never been fully anticipated and planned for. Overcrowded hospitals, countless
deaths, and lack of personal protective equipment to secure their safety, in addition to falling sick themselves, pushed nurses to their limits. Many called nurses
heroes, but nurses time and again shunned that title and responded by saying they
were doing the work they were called to do as nurses, albeit without the equipment, including respirators and personal protective gear, they needed to deliver
care safely. Caring for highly infectious patients with dire needs had sweeping
adverse impacts on the physical and mental health of scores of thousands of the
nation’s nurses.
In addition to the crises created by the pandemic and the trauma it caused for
society at large and nurses, years of racial injustice culminated in tragic events
that also shone a light on inequities for people of color. The tragic deaths of
George Floyd, Breonna Taylor, and countless others unleashed decades of pent-up
emotion and widespread protests regarding the state of equity in the United States
and around the world. These deaths highlighted the reality that serious challenges
were being faced, especially by people of color.
This report’s release in 2021 comes as the United States and the world
have suffered great loss, but also are buoyed by the promise of lessons learned,
including witnessing the nursing profession’s commitment to health, nursing
innovations that improved health care in real time for patients and families impacted by COVID-19, and nurse-driven adaptations in education and practice
that will likely drive lasting changes in both. There is now deeper evidence and
understanding of the differential impact of generations of inequity associated
with racism and bias, socioeconomic status, disabilities, financial poverty, and
living in areas with decreased health care access that has fueled compromised
health status for many of our fellow Americans. It is against this backdrop that
the committee strove to produce a report that would anticipate the needs of the
population and the nursing profession for the next decade while advancing a set
of recommended actions that can make a meaningful impact on deploying the
profession more robustly, so that nurses will be both prepared for disasters in the
3 The figures as of April 13, 2021, were 135.1 million global cases and more than 2.9 million
COVID-related deaths. Nearly 600,000 of these deaths were in the United States. See https://www.
who.int/publications/m/item/weekly-epidemiological-update-on-covid-19—13-april-2021 (accessed
April 13, 2021).
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
PREFACE
xv
future and prepared to engage in the complex but essential work of advancing
health equity, addressing SDOH, and meeting social needs of individuals and
families.
While the 2011 The Future of Nursing report was about building the capacity
of the nursing workforce, this report clearly answers the question of to what end.
Nursing capacity must be brought to bear on the above complex health and social
issues and inequities.
By virtue of its history, its focus, and its presence across sectors and populations, the nursing profession is well positioned to bring its expertise to working
in partnership with other disciplines and sectors to leverage contemporary opportunities and address deep-seated health and social challenges. And the committee
believes that all nurses, at all levels, and no matter the setting in which they work,
have a duty and responsibility to work with other health professionals and sectors
to address SDOH and help achieve health equity.
As was noted in the preface of the 2011 report, “What nursing brings to
the future is a steadfast commitment to patient care, improved safety and quality, and better outcomes.”4 The present report expands that report’s focus on
outcomes by clearly incorporating and leveraging the profession’s own ethics,
values, and knowledge assets to address the upstream and midstream work of
applying evidence linking health and health care equity to health outcomes for
individuals, families, communities, and populations, as well as further building
out evidence-based models, health system policies and health-related public
policies, and educational approaches. Nurses in particular are well prepared to
create, partner in, and lead the complex work of integrating the social and health
sectors in support of the health and well-being of individuals, families, and communities. Nurses, working with social services sectors in and across community-based ambulatory care and public health settings to implement health system
and point-of-care interventions, can help advance continuous care models that are
individual- and population-centered.
In addition to addressing social needs, nurses are called upon to inform and
implement policies that will ultimately affect the greatest numbers of people
in the most profound ways. For decades, the International Council of Nurses
(ICN) has explicitly supported nurses around the world in contributing their
expertise to informing health-related public policy. The ICN has also called for
policy maker receptivity to nurses’ expertise. Nurses recognize that poorly informed public policy, like poor health care and compromised SDOH, can undermine the health of patients, families, and communities. And upstream actions
to address SDOH are often rooted in long-standing policies that contribute to
inequity in housing, employment, education, and other key precursors to health.
4 IOM (Institute of Medicine). 2011. The future of nursing: Leading change, advancing health.
Washington, DC: The National Academies Press.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
xvi
PREFACE
We are grateful to a very committed expert group of committee members
who spent countless hours discussing, debating, and then reaching consensus
around some very difficult topics. In any consensus-building process, not every
individual will agree with every statement in a report such as this, as reflected
in a supplemental statement written by one committee member, provided in Appendix E; the response of the rest of the committee to this statement appears in
Appendix F. The discussion and ultimate set of recommendations in this report
were enhanced by the breadth of expertise brought to bear, expertise that went
far beyond the nursing profession. We are also grateful to the talented staff of the
National Academies of Sciences, Engineering, and Medicine who worked tirelessly with us to create this report. Finally, we appreciate the foresight of RWJF
in valuing the contributions and leadership of nursing in addressing SDOH and
health equity and their sponsorship of this report.
Mary K. Wakefield and David R. Williams, Co-Chairs
Committee on the Future of Nursing 2020–2030
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Dedication
This report is dedicated to the nurses around the world who paid the ultimate
price of caring for people during the COVID-19 crisis of 2020–2021. Hundreds
lost their lives, and many thousands became sick themselves. And those who
escaped the physical symptoms of the illness did not necessarily escape the physical and mental toll of working long hours in grueling circumstances, sometimes
without proper personal protective equipment. Their dedication and persistence
in the face of adversity saved countless lives. They were also there to ease the
suffering of the dying with a hand held, a song sung, or a video call to loved ones.
For them, we look to the future of nursing to help ensure that what happened
to the nursing profession this year and those in their care, especially the disadvantaged and people of color, becomes an event of the past.
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Acknowledgments
To begin, the committee would like to thank the sponsor of this study. Funds
for the committee’s work were provided by the Robert Wood Johnson Foundation
(RWJF).
Numerous individuals and organizations made important contributions to
the study process and this report. The committee wishes to express its gratitude
for each of these contributions, although space does not permit identifying all of
them here. Appendix A lists the individuals who provided valuable information at
the committee’s open workshops and its three town halls on the future of nursing.
The committee thanks the members of the staff of the National Academies of Sciences, Engineering, and Medicine for their significant contributions to the report:
Suzanne Le Menestrel, Susan B. Hassmiller, Jennifer Lalitha Flaubert, Adrienne
Formentos, Tochi Ogbu-Mbadiugha, Cary Haver, Lori Brenig, Carol Sandoval,
Ashley Darcy-Mahoney, and Allison Squires.
The committee would also like to thank Rona Briere, Allison Boman, Diana
Mason, Dalia Sofer, Paul Selker, and Maya Thomas for their writing, editorial,
and fact-checking assistance. The committee would like to especially acknowledge Erin Hammers Forstag for her writing and editing contributions. We would
like to thank National Academies staff members who provided invaluable support
throughout the project: Micah Winograd, senior finance business partner; the late
Daniel Bearss and Anne Marie Houppert, research librarians, for assistance with
literature searches; and staff that contributed additional writing and research,
including Alix Beatty, Bernice Chu, Carolyn Fulco, and Adrienne Stith-Butler.
Thank you to Laura DeStefano, Greta Gorman, Andrew Grafton, Talia Lewis,
Devona Overton, Esther Pak, and Olivia Ramirez for their communications
expertise; Annalee Espinosa Gonzales and Joe Goodman for logistical support
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
xx
ACKNOWLEDGMENTS
in Philadelphia and Seattle; and Sharyl Nass, Tina Seliber, and Lauren Shern
for guidance throughout the study process. The committee appreciates the contributions of Molly Ellison and Janet Firshein, who provided strategic communications support for this report through the communications firm Burness. The
committee would also like to thank Dave McClinton from African American
Graphic Designers for the report cover design and Elena Ovaitt for designing
figures and models for the report.
In conjunction with each of its town halls, the committee also visited several
clinical and community sites to observe clinics and programs that are nurse-led
or where nurses acted as important members of multidisciplinary teams in contributing to health equity and addressing social determinants of health in various
settings. The committee greatly appreciates the time and information provided
by all of these individuals, especially those who helped to coordinate those visits,
including Sue Birch and Azita Emami in Seattle; Kathleen Noonan and Roberta
Waite in Camden, New Jersey, and Philadelphia; and Janice Phillips and Sue
Swider in Chicago.
The committee also gratefully acknowledges the contributions of the individuals who provided data and research support. Margo Edmunds and Raj Sabharwal
of AcademyHealth with a team of research managers, Karen Johnson, Kent Key,
Polly Pittman, and Joanne Spetz, who created research products that synthesized,
translated, and disseminated information to inform the committee’s deliberations.
The committee also acknowledges and greatly appreciates the time and effort of
David Auerbach and Timothy Bates in analyzing workforce data.
The committee would also like to thank the authors whose commissioned
papers added to the evidence base for the study: Amy J. Barton, University of
Colorado College of Nursing; Barbara Brandt and Carla J. Dieter, University of
Minnesota; and Shanita D. Williams, Health Resources and Services Administration; Jack Needleman, Fielding School of Public Health, University of California,
Los Angeles; and Tener Veenema, Johns Hopkins University School of Nursing,
with research assistance from Emily Clifford, Johns Hopkins University.
Finally, the committee acknowledges the following individuals who provided
additional data, reports, and support to the committee: Michelle Adymec, Mavis
Asiedu-Frimpong, Sheila Brown, Laura Buckley, Jess Cordero, Dayna Fondell,
Ebony Haley, Lauran Hardan, Mark Humowiecki, Stephanie Jean-Louis, Andrew Katz, Renee Murray, Victor Murray, Jeneen Skinner, Aaron Truchil, and
Katie Wood, Camden Coalition of Healthcare Providers; Min An, Kline Galland
House; Kate Baber, Downtown Emergency Services Center; Teresita Batayola,
Dante Batingan, Rattana Chaokhote, Asqual Getaneh, Sherryl Grey, DoQuyen
Huynh, Rachel Koh, Rayburn Lewis, Ian Munar, Jackqui Sinatra, Eric Ric Troyer,
and Mayumi Willgerodt, International Community Health Services; Rebecca
Bixby, Laniece Coleman, Joan Gray, Mary Katherine Green, Diana Hartley-Kim,
Lidyvez Sawyer, and Mary Thornton-Bowmer, Stephen and Sandra Sheller 11th
Street Family Health Services, Drexel University; Michelle Cleary, Jesse Dean,
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
ACKNOWLEDGMENTS
xxi
Robin Fleming, Tamarra Henshaw, and Suzanne Swadener, Washington State
Health Care Authority; Rebecca Darmoc, Marquis Forman, Mariela Hernandez,
and Angelique Richard, Rush University College of Nursing; Candice Douglass,
Panome Ratsavong, and Nolan Ryan, University of Washington School of Nursing; Kathy Eaton, Deb Gumbardo, Elizabeth Masse, Erika Miller, Mady Murray,
and Debra Ridling, Seattle Children’s Hospital; Yolanda Fong, Kitsap Public
Health; Theresa Gallagher and Angela Moss, Sue Gin Health Center; Joan Gray,
Tarun Kapoor, and Jubril Oyeyemi, Virtua Health System; Jennifer Grenier and
Nicole Wynn, The Surplus Project; Patty Hayes and Doreen Hersh, Public Health
Seattle & King County; Ayesha Jaco, Westside United and Rush University Medical Center; Jennifer Johnson Joefield, Peninsula Community Health Services;
Sally Lemke, Simpson School Based Health Center; Janice Mason, Malcolm X
Community College; Brenda Montgomery, Harrison Hospital (CHI Franciscan);
Julie Morita, Chicago Department of Public Health; Donna Nickitas, Rutgers
School of Nursing–Camden; William Reedy, Thresholds Community Mental
Health Center; James Rice, City Colleges of Chicago School of Nursing; Cynda
Rushton, Johns Hopkins University School of Nursing; Kelsey Stedman and
Jayme Stuntz, Kitsap Connect; and Janet Tomcavage, University of Pennsylvania
School of Nursing. We would also like to thank the staff of the Seattle Indian
Health Board, Era Living, Ida Culver House, and Salvation Army (Seattle) and
everyone at the Port Gamble S’Klallam Health Center.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Contents
ACRONYMS AND ABBREVIATIONS
xxix
SUMMARY
1
1
INTRODUCTION
17
2
SOCIAL DETERMINANTS OF HEALTH AND
HEALTH EQUITY
31
3
THE NURSING WORKFORCE
59
4
THE ROLE OF NURSES IN IMPROVING HEALTH CARE
ACCESS AND QUALITY
99
5
THE ROLE OF NURSES IN IMPROVING HEALTH EQUITY
127
6
PAYING FOR EQUITY IN HEALTH AND HEALTH CARE
147
7
EDUCATING NURSES FOR THE FUTURE
189
8
NURSES IN DISASTER PREPAREDNESS AND PUBLIC
HEALTH EMERGENCY RESPONSE
247
9
NURSES LEADING CHANGE
275
xxiii
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
xxiv
CONTENTS
10 SUPPORTING THE HEALTH AND PROFESSIONAL
WELL-BEING OF NURSES
301
11 THE FUTURE OF NURSING: RECOMMENDATIONS AND
RESEARCH PRIORITIES
355
APPENDIXES
A BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS
AND PROJECT STAFF
B DATA COLLECTION AND INFORMATION SOURCES
C DATA SOURCES, DEFINITIONS, AND METHODS
D GLOSSARY
E THE FUTURE OF NURSING 2020–2030: MEETING
AMERICA WHERE WE ARE
F COMMITTEE RESPONSE TO SUPPLEMENTAL
STATEMENT
G PROFILES OF NURSING PROGRAMS AND
ORGANIZATIONS
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377
391
405
415
423
429
433
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Boxes, Figures, and Tables
BOXES
S-1
S-2
Achieving Health Equity Through Nursing: Desired Outcomes, 2
The Committee’s Recommendations, 13
1-1
1-2
Types of Nursing Care Providers, 19
Statement of Task, 24
2-1
2-2
Social Determinants of Health, 33
Intersectionality, 38
3-1
3-2
3-3
3-4
Internationally Educated Nurses, 65
COVID-19 and Nurse Staffing in Nursing Homes, 70
Health Disparities Among American Indians/Alaska Natives, 85
Agenda for Nursing Health Services Research, 92
4-1
4-2
4-3
Innovative In-Home Care Programs, 107
Transitional Care Model, 113
Culturally and Linguistically Appropriate Services, 115
5-1
5-2
5-3
Shortcomings of Evaluations of Health Equity Interventions, 130
Examples of Edge Runner Programs, 138
Delaware Cancer Consortium, 140
xxv
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
xxvi
7-1
7-2
7-3
7-4
7-5
7-6
7-7
7-8
BOXES, FIGURES, AND TABLES
National League for Nursing’s (NLN’s) Vision for Integration of the
Social Determinants of Health into Nursing Education Curricula, 194
Domains for Nursing Education, 203
Competencies for Nursing Education, Depending on
Preparation Level, 203
Discussing Difficult Topics, 205
Highlights from the Seattle Townhall on Technology and
Health Equity and Implications for Nursing Education, 210
Pine Ridge Family Health Center, 215
The Community Action Poverty Simulation, 216
Examples of Supports for Nursing Students, 226
8-1
8-2
8-3
Pulse Nightclub Shooting, 254
COVID-19 in Hidalgo County, Texas, 256
Lessons Learned from Nurses’ Role in Evacuation During
Hurricane Sandy, 258
10-1
10-2
10-3
10-4
10-5
10-6
Technological Factors Impacting Nurses’ Well-Being, 305
A Snapshot of the Physical Health of American Nurses, 307
COVID-19 and Nurses’ Health and Well-Being, 309
Mobile Technology and Mental Health Interventions, 323
Examples of Nursing Schools’ Well-Being Initiatives, 330
Psychological Personal Protective Equipment (PPE), 332
11-1
Achieving Health Equity Through Nursing: Desired Outcomes, 356
FIGURES
S-1
A framework for understanding the nurse’s role in addressing the
equity of health and health care, 5
1-1
A framework for understanding the nurse’s role in addressing
the equity of health and health care, 27
2-1
Conceptual framework of the Commission on the Social
Determinants of Health, 35
Social Determinants of Health and Social Needs Model, 37
Expected age at death among 40-year-old men and women, by
household income percentile, 43
2-2
2-3
3-1
3-2
3-3
Number of nursing doctoral graduates by race/ethnicity, 66
Nurse practitioners by race and ethnicity, 2018, 73
Scope of practice for nurse practitioners by state, 87
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
xxvii
BOXES, FIGURES, AND TABLES
4-1
Licensure staffing patterns (paid and unpaid volunteer)
by geography, 110
5-1
Areas of activity that strengthen integration of social care
into health care, 129
7-1
Training topics that would have helped registered nurses
do their jobs better, by type of work performed and graduation
from their nursing program, 2018, 196
Training topics that would have helped nurse practitioners do
their jobs better, by type of work performed and graduation
from their nursing education program, 2018, 197
7-2
8-1
Disaster nursing timeline, 250
10-1
Systems model of burnout and well-being, 304
TABLES
3-1
3-2
3-3
3-4
3-5
3-6
Demographic Characteristics of Full-Time Equivalent (FTE)
Registered Nurses (RNs), 2000–2018, 63
Number and Percentage of Nurses with Various Levels of
Nursing Education by Race, 2018, 64
Number of Registered Nurses (RNs) by Employment Setting,
Average Annual Earnings, and Age, 2018, 66
Number of Employed Advanced Practice Registered Nurses
(APRNs), 2008 and 2018, 72
Nurse Practitioner Employment Settings, 2018, 74
Nurse Practitioner Employment by Clinical Specialty Area,
2018, 76
5-1
Definitions of Areas of Activities That Strengthen Integration of
Social Care into Health Care, 129
7-1
7-2
Pathways in Nursing Education, 192
Number of Graduates from Nursing Programs in the United States
and Territories, 2019, 193
Nursing Program Graduates by Degree Type and by Race/Ethnicity,
2019, 218
Nursing Program Graduates by Degree Type and Gender,
2019, 219
Diversity and Inclusion in Accreditation Standards, 220
7-3
7-4
7-5
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
xxviii
BOXES, FIGURES, AND TABLES
9-1
A Framework for Nurse Leadership, 279
11-1
Research Topics for the Future of Nursing, 2020–2030, 373
C-1
Demographic Characteristics of Full-Time Equivalent (FTE)
Registered Nurses, 2001–2018, 406
Number of Registered Nurses by Employment Settings,
Average Annual Earnings, and Age, 2018, 411
Nurse Practitioner Employment Settings, 2018, 413
C-2
C-3
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Acronyms and Abbreviations
AACN
ACA
ACE
ACEN
ACS
AD
AHA
AHRQ
AMA
ANA
APHA
APM
APRN
ASMN
American Association of Colleges of Nursing
Patient Protection and Affordable Care Act
adverse childhood experience
Accreditation Commission for Education in Nursing
American Community Survey
associate’s degree
American Hospital Association
Agency for Healthcare Research and Quality
American Medical Association
American Nurses Association
American Public Health Association
alternative payment model
advanced practice registered nurse
Academy of Medical-Surgical Nurses
BWH
Bureau of Workforce
CAPABLE
CCNA
CCNE
CDC
CMMI
CMS
CNM
CNS
Community Aging in Place: Advancing Better Living for Elders
Center to Champion Nursing in America
Commission on Collegiate Nursing Education
Centers for Disease Control and Prevention
Center for Medicare & Medicaid Innovation
Center for Medicare & Medicaid Services
certified nurse midwife
certified nurse specialist
xxix
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
xxx
ACRONYMS AND ABBREVIATIONS
COVID-19 coronavirus disease 2019
CPT
Current Procedural Terminology
CRNA
certified registered nurse anesthetist
DNP
doctor of nursing practice
EHR
electronic health record
FEMA
FNS
FQHC
Federal Emergency Management Agency
Frontier Nursing Service
federally qualified health center
HBR
HHS
HIV
HPSA
HRSA
Healthy Baton Rouge
U.S. Department of Health and Human Services
human immunodeficiency virus
health professional shortage area
Health Resources and Services Administration
ICD
IHI
IHS
IOM
International Classification of Diseases
Institute for Healthcare Improvement
Indian Health Service
Institute of Medicine
LVN/LPN
licensed vocational nurse/licensed practical nurse
MACPAC Medicaid and CHIP (Children’s Health Insurance Plan) Payment
and Access Commission
MedPAC
Medicare Payment Advisory Commission
NA
nursing assistant
NACCHO National Association of County and City Health Officials
NACNEP National Advisory Council on Nurse Education and Practice
NASN
National Association of School Nurses
NCLEX-RN National Council Licensure Examination for Registered Nurses
NCSBN
National Council of State Boards of Nursing
NFP
Nurse-Family Partnership
NIH
National Institutes of Health
NINR
National Institute of Nursing Research
NLN
National League for Nursing
NRC
National Research Council
NSSRN
National Sample Survey of Registered Nurses
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
ACRONYMS AND ABBREVIATIONS
xxxi
OADN
OECD
Organization of Associate Degree Nurses
Organisation for Economic Co-operation and Development
PACE
PCMH
PHIN
PHN
PPE
Program of All-Inclusive Care for the Elderly
patient-centered medical home
Public Health Information Network
public health nurse
personal protective equipment
RBRVS
RCT
RHC
RN
RUC
RWJF
resource-based relative value scale
randomized controlled trial
rural health clinic
registered nurse
RVS (relative value scale) Update Committee
Robert Wood Johnson Foundation
SAMHSA
SBHC
SDOH
SNAP
SONSIEL
Substance Abuse and Mental Health Services Administration
school-based health center
social determinants of health
Supplemental Nutrition Assistance Program
Society of Nurse Scientists, Innovators, Entrepreneurs and Leaders
VA
VBP
VHA
U.S. Department of Veterans Affairs
value-based payment
Veterans Health Administration
WHO
World Health Organization
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Summary1
The decade ahead will test the nation’s nearly 4 million nurses in new and complex ways. Nurses live and work at the intersection of health, education, and communities. In the decade since the prior The Future of Nursing report was issued by
the Institute of Medicine, the world has come to understand the critical importance
of health to all aspects of life, particularly the relationship among what are termed
social determinants of health (SDOH), health equity, and health outcomes. In a year
that was designated to honor and uplift nursing (the International Year of the Nurse
and the Midwife 2020), nurses have been placed in unimaginable circumstances
by the COVID-19 pandemic. The decade ahead will demand a stronger, more
diversified nursing workforce that is prepared to provide care; promote health and
well-being among nurses, individuals, and communities; and address the systemic
inequities that have fueled wide and persistent health disparities.
The vision of the Committee on the Future of Nursing 2020–2030, which
informs this report, is the achievement of health equity in the United States built
on strengthened nursing capacity and expertise. By leveraging these attributes,
nursing will help to create and contribute comprehensively to equitable public
health and health care systems that are designed to work for everyone. To achieve
health equity, the committee also envisions a major role for the nursing profession
in engaging in the complex work of aligning public health, health care, social
services, and public policies to eliminate health disparities and achieve health
equity. Specifically, with implementation of this report’s recommendations, the
committee envisions 10 outcomes that position the nursing profession to contribute meaningfully to achieving health equity (see Box S-1).
1 This Summary does not include references. Citations for the discussion presented in the Summary
appear in the subsequent report chapters.
1
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
2
THE FUTURE OF NURSING 2020–2030
BOX S-1
Achieving Health Equity Through
Nursing: Desired Outcomes
• Nurses are prepared to act individually, through teams, and across sectors
to meet challenges associated with an aging population, access to primary
care, mental and behavioral health problems, structural racism, high maternal
mortality and morbidity, and elimination of the disproportionate disease burden
carried by specific segments of the U.S. population.
• Nurses are fully engaged in addressing the underlying causes of poor health.
Individually and in partnership with other disciplines and sectors, nurses act on
a wide range of factors that influence how well and long people live, helping
to create individual- and community-targeted solutions, including a health in
all policies orientation.
• Nurses reflect the people and communities served throughout the nation,
helping to ensure that individuals receive culturally competent, equitable health
care services.
• Health care systems enable and support nurses to tailor care to meet the
specific medical and social needs of diverse patients to optimize their health.
• Nurses’ overarching contributions, especially those found beneficial during the
COVID-19 pandemic, are quantified, extended, and strengthened, including
the removal of institutional and regulatory barriers that have prevented nurses
from working to the full extent of their education and training. Practice settings
that were historically undercompensated, such as public health and school
nursing, are reimbursed for nursing services in a manner comparable to that
of other settings.
• Nurses and other leaders in health care and public health create organizational
structures and processes that facilitate the profession’s expedited acquisition
of relevant content expertise to serve flexibly in areas of greatest need in times
of public health emergencies and disasters.
• Nurses consistently incorporate a health equity lens learned through revamped
academic and continuing education.
• Nurses collaborate across their affiliated organizations to develop and deploy a
shared agenda to contribute to substantial, measurable improvement in health
equity. National nursing organizations reflect an orientation of diversity, equity,
and inclusion within and across their organizations.
• Nurses focus on preventive person-centered care and have an orientation
toward innovation, always seeking new opportunities for growth and development. They expand their roles, work in new settings and in new ways, and
markedly expand their partnerships connecting health and health care with all
individuals and communities.
• Nurses attend to their own self-care and help to ensure that nurse well-being
is addressed in educational and employment settings through the implementation of evidence-based strategies.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
3
SUMMARY
HEALTH AND HEALTH INEQUITIES
Health inequities, defined as “systematic differences in the opportunities that
groups have to achieve optimal health, leading to unfair and avoidable differences
in health outcomes,” disproportionately impact people of color; the lesbian, gay,
bisexual, transgender, and queer (LGBTQ) community; people with disabilities;
those with low income; and those living in rural areas. Indeed, growing evidence
reveals a clear association between inequities in both health and access to health
care and SDOH—the conditions in the environments in which people live, learn,
work, play, worship, and age that affect a wide range of health, functioning, and
quality-of-life outcomes and risks. SDOH include both the positive and negative
aspects of these conditions. Examples of SDOH include education, employment,
health systems and services, housing, income and wealth, the physical environment, public safety, the social environment (including structures, institutions, and
policies), and transportation. Everyone is affected by SDOH. Some people who
have more education or higher incomes will fare better healthwise as they may
be able to make more informed choices, have better opportunities to access health
care, and have the means to pay for health care. Others, without the benefit of
these positive social determinants, are unlikely to fare as well.
A related concept is social needs—individual-level, nonmedical, acute resource needs for such things as housing, reliable transportation, and a strong
support system at home that are necessary for good health outcomes and health
equity. Health equity can be advanced at the individual level by addressing these
needs and at the population level by addressing SDOH. Health equity benefits
all individuals by promoting such macrostructural benefits as economic growth,
a healthier environment, and national security.
For too long, the United States has overinvested in treating illness and underinvested in promoting health and preventing disease. The nation has spent
more on medical care than any other high-income country, yet it has seen consistently worse health outcomes than those of its peer countries, including the
lowest life expectancy, more chronic health conditions, and the highest rates of
infant mortality. At the same time, the COVID-19 pandemic has starkly revealed
Americans’ unequal access to opportunities to live a healthy life, often resulting
from entrenched structural and systemic barriers that include poverty, racism, and
discrimination. These two phenomena—suboptimal health outcomes and inequities in health and health care—are not unrelated. If the nation is to achieve better
population health, it will have to meet the challenge of mitigating these inequities.
Herein lies the greatest contribution of the nursing workforce in the decade ahead.
THE ROLE OF NURSES IN ADVANCING HEALTH EQUITY
A nation cannot fully thrive until everyone—no matter who they are, where they
live, or how much money they make—can live the healthiest possible life, and help-
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
4
THE FUTURE OF NURSING 2020–2030
ing people live their healthiest life is and has always been the essential role of nurses.
Whether in a school, a hospital, or a community health clinic, they have worked to
address the root causes of poor health. The history of nursing is grounded in social
justice and community health advocacy. The Code of Ethics for Nurses with Interpretive Statements from the American Nurses Association (ANA), for example, obligates nurses to “integrate principles of social justice into nursing and health policy.”2
Nurses work in a wide array of settings and practice at a range of professional levels. They often act as the first and most frequent line of contact with
people of all backgrounds and experiences seeking care. The nursing workforce
also represents the largest of the health care professions—nearly four times
the size of the physician workforce. In their various capacities and given their
numbers, nurses are uniquely positioned to manage teams and link clinical care,
public health, and social services.
STUDY PURPOSE AND APPROACH
Nurses, then, have a critical role to play in achieving the goal of health equity. But to take on the pursuit of that goal, they need robust education, supportive
work environments, and autonomy. Accordingly, the Robert Wood Johnson Foundation asked the National Academies of Sciences, Engineering, and Medicine
to conduct a study aimed at charting a path forward for the nursing profession
to help create a culture of health and reduce disparities in people’s ability to
achieve their full health potential. To carry out this study, the National Academies
convened an ad hoc committee of 15 experts in the fields of nursing leadership,
education, practice, and workforce, as well as health policy, economics and health
care finance, informatics, population health and health disparities, health care
quality and delivery, and health care research and interventions.
To supplement the knowledge and expertise of its members, the committee
solicited input from additional experts and interested members of the public at
two public sessions held in conjunction with committee meetings. Further input
came from several site visits that included town hall meetings. In addition, the
committee reviewed the salient peer-reviewed and grey literature not associated
with commercial publishers, carried out original data analyses, commissioned
papers on topics of particular relevance, and considered public and organizational
statements pertinent to this study.
To organize and consolidate this wealth of information, the committee developed the framework depicted in Figure S-1. This framework structures the
report’s discussion of the key areas for strengthening the nursing profession to
meet the challenges of the decade ahead. The heart of this framework is the key
areas shown at the top of the figure: the nursing workforce, leadership, nursing
2 See https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-fornurses/coe-view-only (accessed April 13, 2021).
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
5
SUMMARY
NURSE’S ROLE IN ADDRESSING HEALTH EQUITY AND HEALTH CARE EQUITY
KEY AREAS FOR STRENGTHENING NURSING
Workforce | Leadership | Education | Well-being | Emergency Preparedness/Response
NURSING ROLES*
DETERMINANTS OF HEALTH
Medical
and Social
Structural
PAYMENT,
LAWS,
POLICIES,
AND
REGULATIONS
Individual
HEALTH EQUITY AND HEALTH CARE EQUITY
Improved Individual and Population Health
EVOLVING TRENDS
Demographics | Technology | Care Models | Public Health Emergencies | Attitudes Toward Racism and Equity
FIGURE S-1 A framework for understanding the nurse’s role in addressing the equity of
health and health care.
* Examples of nursing roles in acute, community, and public health settings include
care coordinator, policy maker, clinician, educator, researcher/scientist, administrator, and
informaticist.
*Examples of nursing roles in acute, community, and public health settings include:
Care Coordinator, Policy Maker, Clinician, Advocate, Educator, Researcher/Scientist, Administrator, Informaticist
education, nurse well-being, and emergency preparedness and response, and the
responsibilities of nursing with respect to structural and individual determinants
of health. Nurses play multiple roles in acute, community, and public health settings that include, but are not limited to, care team member and leader, primary
care provider, patient and family advocate, population health coordinator, educator, public health professional, health systems leader, organizational and public
policy maker, researcher and scientist, and informaticist. Through each of these
roles, nurses impact the medical and social factors that drive health outcomes and
health and health care equity. Nurses can address SDOH through interventions at
both the individual level (e.g., referring an individual’s family to a food assistance
program) and the structural level (e.g., alleviating the problem of food insecurity
in the community). Similarly, nurses can address medical determinants of health
at both the individual level (e.g., providing patient education and medication
management) and the structural level (e.g., implementing a system of team-based
multisector care that includes coordination of care across settings and sectors).
ACTING NOW TO IMPROVE THE HEALTH
AND WELL-BEING OF THE NATION
The health and well-being of the nation are at an inflection point. In the
decade ahead, in addition to growth in the overall size of the U.S. population,
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
6
THE FUTURE OF NURSING 2020–2030
other sociodemographic factors and health workforce imbalances will increase
the demand for nurses, particularly in areas in which the current registered nurse
(RN) and advanced practice registered nurse (APRN) workforce is inadequate
to meet the nation’s health care needs. For instance, a 2020 report prepared for
the American Association of Medical Colleges estimated that by 2033, current
physician shortages, seen particularly in the areas of primary care, mental health,
and gerontology and in rural areas, could increase—for primary care physicians,
ranging between 21,400 and 55,200, and for non–primary care specialty physicians, between 33,700 and 86,700. Salient sociodemographic factors include
the aging population, the increasing incidence of mental and behavioral health
conditions, increases in lack of access to primary health care, persistently high
maternal mortality rates, and worsening physician shortages. For example, the
aging of the U.S. population means that over this decade, increasing numbers of
people will age into their 70s, 80s, 90s, and beyond. In 2030, 73.1 million people,
or 21 percent of the U.S. population, will be older than 65—a population that typically presents with morbidities at higher rates than are seen in younger people.
The strengths of the nursing workforce are many, yet they will be tested by
formidable challenges that are already beginning to affect nurses and the health
systems and organizations in which they work. These challenges will arise not
only from the above changes occurring throughout the broader society but also
from changes within the health care system itself and within the nursing and
larger health care workforce. Further challenges for nursing will arise from
health-related public policies and other factors that affect the scope of practice,
size, distribution, diversity, and educational preparation of the nursing workforce.
These many challenges include the need to
•
•
•
•
•
•
increase the number of nurses available to meet the nation’s growing
health care needs;
rightsize the clinical specialty distribution of nurses;
increase the distribution of nurses to where they are needed most;
ensure a nursing workforce that is diverse and prepared with the knowledge and skills to address SDOH;
overcome current and future barriers affecting workforce capacity; and
anticipate long-term impacts of the COVID-19 pandemic on the nursing
workforce.
Conclusion 3-1: A substantial increase in the numbers, types, and distribution of members of the nursing workforce and improvements in
their knowledge and skills in addressing social determinants of health
are essential to filling gaps in care related to sociodemographic and
population factors. These factors include the aging population, the
increasing incidence of mental and behavioral health conditions, and
the increasing lack of access to primary and maternal health care.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
7
SUMMARY
Access to comprehensive health services is an essential precursor to equitable, high-quality health care. Nurses can help advance health care equity and
improve health outcomes by assisting people in navigating the health care system,
providing close monitoring and follow-up across the care continuum, focusing
care on the whole person, and providing care that is appropriate and shows cultural humility.3 In the current system, care is often disjointed. Nurses can provide
care management that helps ensure seamless care, serve as advocates for patients
and communities, and assist in increasing individuals’ trust in and engagement
with the health care system.
Lifting Barriers to Expand the Contributions of Nursing
Nurses can address SDOH and help improve health equity by providing
care management and team-based care; expanding the capacity of primary care,
including maternal and pediatric care, mental health care, and telehealth; and
providing care in school, home, work, and public health settings. Yet, their ability
to fulfill this potential is limited by state-level regulations restricting nurse practitioners’ (NPs’) scope of practice. While considerable progress has been made
over the past two decades in lifting such regulations, 27 states still do not allow
full practice authority for NPs. As of January 2021, 23 states and the District of
Columbia allowed full practice authority for NPs, permitting them to prescribe
medication, diagnose patients, and provide treatment without the presence of a
physician. In 16 states, NPs need a physician’s authority to prescribe medication,
and in 11 states, they require physician oversight for all practice.
Conclusion 3-2: Eliminating restrictions on the scope of practice of
advanced practice registered nurses and registered nurses so they can
practice to the full extent of their education and training will increase
the types and amount of high-quality health care services that can be
provided to those with complex health and social needs and improve
both access to care and health equity.
Designing Better Payment Models
How care is paid for can directly influence access to care. The design of payment systems influences what health care is provided to individuals and communities, where care is provided, and by whom. Positioning health systems to work
in partnership with other sectors to meet the complex health and social needs of
individuals can help reduce health inequities. However, current payment systems
are not designed to pay for services—including those provided by nurses, such as
3 Cultural humility is “defined by flexibility; awareness of bias; a lifelong, learning-oriented approach to working with diversity; and a recognition of the role of power in health care interactions.”
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THE FUTURE OF NURSING 2020–2030
supporting team-based care and advancing proven interventions and strategies for
reducing health disparities—that address social needs and SDOH. Going forward,
payment systems need to be redesigned to recognize the value of those services.
Nurses are essential to whole-person care through their vital roles in coordinating and managing care, helping people navigate the health care system, and
providing health education, as well as addressing SDOH and advancing health
equity. By supporting team-based care, improved communication, and proven
interventions and strategies that can reduce health disparities, payment systems
can enable nurses to make these essential contributions to improving care and
outcomes for all patients.
Conclusion 6-3: Payment mechanisms need to be designed to support
the nursing workforce and nursing education in addressing social
needs and social determinants of health in order to improve population
health and advance health equity.
New payment models, such as accountable care organizations (ACOs), accountable health communities (AHCs), and value-based payment (VBP), can
give health care organizations the flexibility to pursue these goals. Changing
the ways in which the nation pays for health care will cause discomfort among
some, but will also stimulate those seeking innovative ways of maximizing the
population’s health. Payment reform represents an opportunity to consider who
has access to health care and who does not, what types of services are needed to
improve individual and population health, and how the nation’s resources can be
used most wisely to these ends.
Strengthening Nursing Education
Nursing education needs to be markedly strengthened to prepare nurses to
identify and act on the complex social, economic, and environmental factors that
influence health and well-being. In particular, their education needs to provide
nursing students with substantive, diverse, and sustained community-based experiences, as well as to substantially reorient curricula and reevaluate hiring and
admission practices so as to achieve a diverse faculty and student population.
Nursing organizations have developed guidelines for how nursing education
should prepare nurses to address health equity issues and SDOH in a meaningful
way. The American Association of Colleges of Nursing’s (AACN’s) Essentials
provides an outline for the necessary curriculum content and expected competencies for graduates of baccalaureate, master’s, and doctor of nursing practice (DNP)
programs. Yet, despite this guidance and the numerous calls to incorporate equity,
population health, and SDOH into undergraduate and graduate nursing education,
these and related concepts are currently not well integrated into nursing curricula.
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
SUMMARY
9
Conclusion 7-1: A curriculum embedded in coursework and experiential learning that effectively prepares students to promote health equity,
reduce health disparities, and improve the health and well-being of the
population will build the capacity of the nursing workforce.
Nursing is increasingly practiced in community settings, such as schools and
workplaces, as well as through home health care and public health clinics. Other
innovative care delivery models are situated in libraries and homeless shelters
and implemented through telehealth visits. Nursing students are prepared to
practice in hospitals, but do not necessarily receive the same level of training and
preparation for community and telehealth settings. Education in the community
allows nursing students to learn about the broad range of care environments and
to work collaboratively with other professionals who work in these environments,
including those from nonhealth sectors.
Conclusion 7-3: Learning experiences that develop nursing students’
understanding of health equity, social determinants of health, and
population health and prepare them to incorporate that understanding
into their professional practice include opportunities to
• learn cultural humility and recognize one’s own implicit biases;
• gain experience with interprofessional collaboration and multisector partnerships to enable them to address social needs
comprehensively and drive structural improvements;
• develop such technical competencies as use of telehealth, digital health tools, and data analytics; and
• gain substantive experience with delivering care in diverse
community settings, such as public health departments,
schools, libraries, workplaces, and neighborhood clinics.
Building a diverse nursing workforce is a critical part of preparing nurses to
address SDOH and health equity. While the nursing workforce has steadily grown
more diverse, nursing schools need to continue and expand their efforts to recruit
and support diverse students that reflect the populations they will serve.
Conclusion 7-4: Successfully diversifying the nursing workforce will
depend on holistic efforts to support and mentor/sponsor students and
faculty from a wide range of backgrounds, including cultivating an
inclusive environment; providing economic, social, professional, and
academic supports; ensuring access to information on school quality;
and minimizing inequities.
Copyright National Academy of Sciences. All rights reserved.
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THE FUTURE OF NURSING 2020–2030
Valuing Community Nursing
School and public health nurses play a vital role in advancing health equity.
Adequate funding for these nurses is essential if they are to take on that role.
School nurses are front-line health care providers, serving as a bridge between the
health care and education systems and other sectors. Whether they are hired by
school districts, health departments, or hospitals, school nurses focus on the physical and mental health of students in the context of educational environments.
They serve as both essential care providers for individuals and links to broader
community health issues through the student populations they serve.
School nurses are a particularly critical resource for students experiencing
such challenges as food insecurity, homelessness, and living in impoverished
circumstances, for whom the school nurse may be the only health care professional they see regularly. Accordingly, access to a school nurse is a health care
equity issue for some students, especially in light of the increasing number of
students who have complex health needs. School nurses also are well positioned
to work with students and families in their neighborhoods and homes to address
individual and family social needs, such as access to care, healthy food, and safe
and healthy environments/neighborhoods. More school nurses need the practice
authority to address in creative ways the complex health and social needs of the
populations they serve.
Likewise, the COVID-19 pandemic has highlighted the pivotal role of nurses
in improving health care equity. During the pandemic, public health and hospital
nurses have had to work synergistically both to help flatten the infection curve
and support mitigation strategies (public health nurses) and to care for the sick
and critically ill (inpatient and intensive care unit [ICU] nurses). The pandemic
also has heightened the need for team-based care, infection control, person-centered care, and other skills that reflect the strengths of community nurses.
Fostering Nurses’ Roles as Leaders and Advocates
Creating a future in which opportunities to optimize health are more equitable will require disrupting the deeply entrenched prevailing paradigms of health
care, which in turn will require enlightened, diverse, courageous, and competent
leadership. Nurses have always been key to the health and well-being of patients
and communities, but a new generation of nurse leaders is now needed—one
that recognizes the importance of diversity and is able to use and build on the
increasing evidence base supporting the link between SDOH and health status.
Today’s nurses are called on to lead in the development of effective strategies for
improving the nation’s health with due attention to the needs of the most underserved individuals, neighborhoods, and communities and the crucial importance
of advancing health equity. Implementing change to address SDOH and advance
health equity will require the contributions of nurses in all roles and all settings;
although no one nurse can successfully implement change without the collabo-
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
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SUMMARY
ration of others. In addition to collaboration among members of the nursing profession, the creation of enduring change will require the involvement of patients
and community members. Rather than a more hierarchal system of leadership,
moreover, collaborative leadership assumes that everyone involved has unique
contributions to make and that constructive dialogue and joint resources are
needed to achieve ongoing goals.
Conclusion 9-1: Nurse leaders at every level and across all settings can
strengthen the profession’s long-standing focus on social determinants
of health and health equity to meet the needs of underserved individuals, neighborhoods, and communities and to prioritize the elimination
of health inequities.
Racism and discrimination are deeply entrenched in U.S. society and its institutions, and the nursing profession is no exception. Nurse leaders can play an
important role in acknowledging the history of racism within the profession and
in helping to dismantle structural racism and mitigate the effects of discrimination
and implicit bias on health. If they are to take on this role, it will be essential
to build a more diverse nursing workforce and support nurses of diverse backgrounds in pursuing leadership roles.
Conclusion 9-4: Nurse leaders have a responsibility to address structural racism, cultural racism, and discrimination based on identity
(e.g., sexual orientation, gender), place (e.g., rural, urban), and circumstances (e.g., disability, mental health condition) within the nursing profession and to help build structures and systems at the societal
level that address these issues to promote health equity.
Preparing Nurses to Respond to Disasters
The increasing frequency of natural and environmental disasters and public
health emergencies, such as the COVID-19 pandemic, reveals in stark detail
the critical importance of having a national nursing workforce prepared with
the knowledge, skills, and abilities to respond to these events. COVID-19 has
revealed deep chasms within an already fragmented U.S. health care system,
resulting in significant excess mortality and morbidity, glaring health inequities,
and the inability to contain a rapidly escalating pandemic. Most severely—and
unfairly—affected are individuals and communities of color, who suffer from the
compound disadvantages of racism, poverty, workplace hazards, limited health
care access, and preexisting health conditions resulting from the foregoing factors. As other disasters and public health emergencies threaten population health
in the decades ahead, articulation of the roles and responsibilities of nurses in
disaster response and public health emergency management will be critical to the
nation’s capacity to plan for and respond to these types of events.
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THE FUTURE OF NURSING 2020–2030
Conclusion 8-2: A bold and expansive effort, executed across multiple
platforms, will be needed to fully support nurses in becoming prepared
for disaster and public health emergency response. It is essential to
convene experts who can develop a national strategic plan articulating the existing deficiencies in this regard and action steps to address
them, and, most important, establishing where responsibility will lie
for ensuring that those action steps are taken.
Supporting the Health and Well-Being of Nurses
Nurses’ health and well-being are affected by the demands of their workplace, and in turn affect the quality and safety of the care they provide. Thus, it
is essential to address the systems, structures, and policies that create workplace
hazards and stresses that lead to burnout, fatigue, and poor physical and mental
health among the nursing workforce. With the emergence of COVID-19, the
day-to-day demands of nursing have been both illuminated and exacerbated.
Nurses are coping with unrealistic workloads; insufficient resources and protective equipment; risk of infection; stigma directed at health care workers; and
the mental, emotional, and moral burdens of caring for patients with a new and
unpredictable disease and helping with contact tracing and testing. Moreover, if
nurses are to contribute to addressing the many social determinants that influence
health, they must first feel healthy, well, and supported themselves. Policy makers, employers of nurses, nursing schools, nurse leaders, and nursing associations
all have a role to play to this end.
Conclusion 10-1: All environments in which nurses work affect the
health and well-being of the nursing workforce. Ultimately, the health
and well-being of nurses influence the quality, safety, and cost of the
care they provide, as well as organizations and systems of care. The
COVID-19 crisis has highlighted the shortcomings of historical efforts
to address nurses’ health and well-being.
RECOMMENDATIONS
The committee’s recommendations (see Box S-2) call for change at both the
individual and system levels, constituting a call for action to the nation’s largest
health care workforce, including nurses in all settings and at all levels, to listen,
engage, deeply examine practices, collect evidence, and act to move the country
toward greater health equity for all. The committee’s recommendations also are
targeted to the actions required of policy makers, educators, health care system
leaders, and payers to enable these crucial changes.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
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SUMMARY
BOX S-2
The Committee’s Recommendations
Recommendation 1: In 2021, all national nursing organizations should initiate
work to develop a shared agenda for addressing social determinants of health and
achieving health equity. This agenda should include explicit priorities across nursing practice, education, leadership, and health policy engagement. The Tri-Council
for Nursinga and the Council of Public Health Nursing Organizations,b with their
associated member organizations, should work collaboratively and leverage their
respective expertise in leading this agenda-setting process. Relevant expertise
should be identified and shared across national nursing organizations, including
the Federal Nursing Service Councilc and the National Coalition of Ethnic Minority
Nurse Associations. With support from the government, payers, health and health
care organizations, and foundations, the implementation of this agenda should
include associated timelines and metrics for measuring impact.
Recommendation 2: By 2023, state and federal government agencies, health
care and public health organizations, payers, and foundations should initiate substantive actions to enable the nursing workforce to address social determinants
of health and health equity more comprehensively, regardless of practice setting.
Recommendation 3: By 2021, nursing education programs, employers, nursing
leaders, licensing boards, and nursing organizations should initiate the implementation of structures, systems, and evidence-based interventions to promote
nurses’ health and well-being, especially as they take on new roles to advance
health equity.
Recommendation 4: All organizations, including state and federal entities and
employing organizations, should enable nurses to practice to the full extent of
their education and training by removing barriers that prevent them from more fully
addressing social needs and social determinants of health and improving health
care access, quality, and value. These barriers include regulatory and public and
private payment limitations; restrictive policies and practices; and other legal,
professional, and commerciald impediments.
Recommendation 5: Federal, tribal, state, local, and private payers and public
health agencies should establish sustainable and flexible payment mechanisms
to support nurses in both health care and public health, including school nurses,
in addressing social needs, social determinants of health, and health equity.
Recommendation 6: All public and private health care systems should incorporate
nursing expertise in designing, generating, analyzing, and applying data to support
initiatives focused on social determinants of health and health equity using diverse
digital platforms, artificial intelligence, and other innovative technologies.
Recommendation 7: Nursing education programs, including continuing education, and accreditors and the National Council of State Boards of Nursing should
continued
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THE FUTURE OF NURSING 2020–2030
BOX S-2 Continued
ensure that nurses are prepared to address social determinants of health and
achieve health equity.
Recommendation 8: To enable nurses to address inequities within communities,
federal agencies and other key stakeholders within and outside the nursing profession should strengthen and protect the nursing workforce during the response
to such public health emergencies as the COVID-19 pandemic and natural disasters, including those related to climate change.
Recommendation 9: The National Institutes of Health, the Centers for Medicare
& Medicaid Services, the Centers for Disease Control and Prevention, the Health
Resources and Services Administration, the Agency for Healthcare Research
and Quality, the Administration for Children and Families, the Administration for
Community Living, and private associations and foundations should convene
representatives from nursing, public health, and health care to develop and support a research agenda and evidence base describing the impact of nursing
interventions, including multisector collaboration, on social determinants of health,
environmental health, health equity, and nurses’ health and well-being.
a The Tri-Council for Nursing includes the following organizations as members: the
American Association of Colleges of Nursing, the American Nurses Association, the American
Organization for Nursing Leadership, the National Council of State Boards of Nursing,
and the National League for Nursing.
b The Council of Public Health Nursing Organizations includes the following
organizations as members: the Alliance of Nurses for Healthy Environments, the American Nurses Association, the American Public Health Association—Public Health Nursing
Section, the Association of Community Health Nursing Educators, the Association
of Public Health Nurses, and the Rural Nurse Organization.
c The Federal Nursing Service Council is a united federal nursing leadership team representing the U.S. Army, Air Force, Navy, National Guard and Reserves, Public Health
Service Commissioned Corps, American Red Cross, U.S. Department of Veterans Affairs,
and Uniformed Services University of the Health Sciences Graduate School of Nursing.
d The term “commercial” refers to contractual agreements and customary practices that
make antiquated or unjustifiable assumptions about nursing.
FINAL THOUGHTS
In conclusion, the nation will never fully thrive until everyone can live the
healthiest possible life. Promoting health and well-being has always been nurses’
business. Thus, it is essential to harness the vast expertise and untapped potential
of nurses at every level and in every setting to build healthy communities for all.
As evidenced in this report, nurses are bridge builders and collaborators who engage and connect with people, communities, and organizations to promote health
and well-being. But they need ongoing support from the systems that educate,
train, employ, and enable them to advance health equity. As of this writing, the
COVID-19 pandemic has starkly revealed the challenges nurses face every day.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
SUMMARY
15
But this crisis has also given some nurses more autonomy, shifted payment models, and sparked overdue conversations about dismantling racism in health care.
Policy makers and system leaders must seize this moment to support, strengthen,
and transform the largest segment of the health care workforce so nurses can help
chart the nation’s course to good health and well-being for all. Over the course of
this decade, nurses will face a host of challenges—from addressing the lasting effects of COVID-19 on themselves and their communities to dismantling the racist
systems that create and perpetuate inequities. No one is immune from hate and
bigotry, but everyone has the capacity for empathy, understanding, and solidarity
in a shared hope for a more just and equitable world. The nursing profession is
resilient and well positioned to help usher in a new era in which everyone has a
chance to live the healthiest possible life.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
1
Introduction
It will never be comfortable or easy to advocate for change, but I am
a nurse leader because I am comfortable with being uncomfortable….
I am unafraid to use my voice to influence positive change.
In doing so, I have taught others how to advocate and inspired
others to use their voices as well.
—Andrea Riley, RN, Nebraska 40 Under 40 Leader
Two decades ago, the Institute of Medicine (IOM) published Crossing the
Quality Chasm: A New Health System for the 21st Century (IOM, 2001). That report delineates six aims for improving health care to reduce the burden of illness,
injury, and disability and improve the functioning of the people of the United
States. With the explicit purpose of securing these benefits for all people, equity
was included as one of the six aims, incorporating a focus on both individuals
and the population. In the intervening 20 years, among the six aims, equity in
health and health care has been perhaps the least understood, considered, and
addressed—until now.
Today, a rapidly growing body of evidence documenting the relationship
among social determinants of health (SDOH), inequity in health and health care,
and the health status of individuals and populations is generating a widespread
call to action. Because of its impact on health status, achieving health equity is
urgent. Achieving this goal will require stakeholders, including nurses and the
nursing profession, to focus singular attention on closing the chasm between what
is known about equity in health and health care and what can be done to achieve
it. The 2011 IOM report The Future of Nursing: Leading Change, Advancing
Health focuses on actions that can build critical capacity in nursing to meet
increased demand for care and advance health system improvement. Significant
progress has been made in building the capacity called for in that report; however,
more remains to be done.
The vision of the Committee on the Future of Nursing 2020–2030, which
informs this report, is the achievement of health equity in the United States built
on strengthened nursing capacity and expertise. By leveraging these attributes,
nursing will help to create and contribute comprehensively to equitable public
17
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
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THE FUTURE OF NURSING 2020–2030
health and health care systems that are designed to work for everyone. To achieve
health equity, the committee also envisions a major role for the nursing profession
in engaging in the complex work of aligning public health, health care, social services, and public policies to eliminate health disparities and achieve health equity.
To provide a broad and deep foundation from which to achieve this vision,
the committee formulated nine recommendations (see Chapter 11) that touch
on virtually every component of the nursing profession. Implementing these
recommendations to achieve the committee’s vision will require substantive and
sustained action by the nursing profession. Nursing will need to consider and
reset components of education, leadership, practice, and research, as well as the
structures and priorities of vitally important nursing organizations. Nurses will
need new knowledge on which to act, and the profession itself will need to reflect
the diversity of the populations it serves. Nurses working in all settings will need
to be prepared to participate on and lead multidisciplinary teams and multisector
partnerships and, through data development, management, and use, identify and
respond to challenges that disproportionately affect some segments of the U.S.
population, ranging from public health emergencies to community characteristics.
The committee recognizes the significant scope and scale of its recommendations and the associated efforts required to implement them. Mobilizing to take
the actions called for in this report will require change, commitment, and perseverance. Nurses will also need courage to engage in difficult conversations about
racial inequities, address their own biases and those in the institutions where they
work, and then participate actively in calling out and breaking down structural
racism. Given the evidence delineating the adverse impacts of inequity on health,
operationalizing the recommendations in this report will uphold nursing’s social
responsibility to improve the health of all people.
The committee also notes, however, that for nursing to make the substantive
contributions needed to advance health equity, the profession will require resources, autonomy, and positions of leadership as called for in this report. Across
the coming decade, nurses will be key contributors to the substantial progress
toward health and health care equity that is needed in the United States. They
will do so by taking on expanded roles, working in new settings in innovative
ways, and partnering with communities and other sectors. Achieving this vision
will require much more rapid, substantive, and widespread efforts than those
undertaken to date. If the path set forth in this report and its recommendations
are followed, the committee envisions that this decade will usher in a new era of
promoting health equity and well-being for all, and the nursing profession will
have contributed substantially to making this so.
THE NURSING PROFESSION
Nursing is the nation’s largest health profession, numbering close to 4 million nurses in 2018 (HRSA, 2021). There are three categories of nurses, based on
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
19
INTRODUCTION
education—licensed practical nurses (LPNs)/licensed vocational nurses (LVNs),
registered nurses (RNs), and advanced practice registered nurses (APRNs)—
practicing in many different specialties and settings (see Box 1-1). More information about the current and future nursing workforce can be found in Chapter 3.
BOX 1-1
Types of Nursing Care Providers
Licensed practical nurses (LPNs)/licensed vocational nurses (LVNs) support
the health care team and perform basic tasks, such as taking vital signs; administering medications; changing wound dressings; and ensuring that patients are
comfortable and receive nutrition and hydration. LPNs/LVNs complete a 12- to
18-month-long education program at a vocational/technical school or community
college, and are required to take a nationally standardized licensing exam in the
state where they begin practice (IOM, 2011). In nursing homes, where they predominate, they supervise nurse aides to oversee care. LPNs/LVNs can become
registered nurses (RNs) through an associate’s degree or a baccalaureate in
nursing bridge programs.
Registered nurses (RNs) provide preventive, primary, and acute care in collaboration with other health professionals. Their roles vary enormously by setting but
can include such activities as conducting health assessments and taking health
histories, looking for signs that health is deteriorating or improving, providing counseling and education to promote health and manage chronic disease, administering
medications and other personalized interventions and treatments, and coordinating
care. They work across the continuum of care in all health care and public health
settings in a variety of interprofessional and multisector teams. RNs are required
to take a nationally standardized licensing exam after completing a program at a
community college, diploma school, or 4-year college or university. There are more
than 50 specialty certifications for RNs, including critical care, home health and
hospice, occupational and employee health, oncology, perioperative and operating
room, rehabilitation, psychiatric and mental health, and school nursing.
Advanced practice registered nurses (APRNs) hold at least a master’s degree
in addition to the initial nursing education and licensing required for all RNs, and
may continue in clinical practice or prepare for administrative and leadership positions. The responsibilities of an APRN include, but are not limited to, providing
primary and preventive health care to the public and prescribing medications
and tests when needed. APRNs treat and diagnose illnesses, advise the public
on health issues, manage chronic disease, and coordinate care. They work in a
variety of interprofessional and multisector teams. There are four categories of
APRNs: certified nurse midwife, who provides a “full range of primary health care
services to women throughout the lifespan,” including gynecologic and obstetric
care; clinical nurse specialist, who “integrates care across the continuum […
with a goal of] continuous improvement of patient outcomes and nursing care”;
certified registered nurse anesthetist, who provides a “full spectrum of patients’
anesthesia care and anesthesia-related care for individuals across the lifespan”;
continued
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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity
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THE FUTURE OF NURSING 2020–2030
BOX 1-1 Continued
and certified nurse practitioner, who provides a range of specialized services in
primary, acute, and specialty health care across s…

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